Effectiveness and Safety of Sacral Neuromodulation in Patients With Idiopathic Slow-transit Constipation

Overview

Rationale: Previous reviews showed that the evidence regarding the effectiveness of sacral neuromodulation (SNM) in patients with therapy-resistant, idiopathic (slow-transit) constipation is of suboptimal quality. Furthermore, there is no estimate of costs and cost-effectiveness in this patient group. Study design: A prospective cohort study with one group. This study is conducted next to a randomized controlled clinical trial (RCT) on 'the effectiveness and cost-effectiveness of sacral neuromodulation in patients with idiopathic slow-transit constipation refractory to conservative treatments' (for more information ClinicalTrial.gov ID: NCT02961582). This RCT is part of a temporary reimbursement arrangement, called conditional reimbursement of health care (in Dutch: Voorwaardelijke Toelating) of the National Health Care Institute (Zorginstituut Nederland). As part of this arrangement, the Ministry of Health, Welfare and Sports requires that SNM remains available for eligible patients during the conditional reimbursement period, also when inclusion of the RCT has ended. Furthermore, the Ministry requires that patients who received personalized conservative treatment in the RCT (control group), are offered SNM after completion of their follow-up of 6 months. As a result, the National Health Care Institute requires that the patients who receive SNM outside the RCT are included in a prospective cohort study to be able to collect data on them. Aim: The aim of this prospective cohort study is to collect more (but uncontrolled) information regarding the safety and effectiveness of SNM. Study population: Adolescent (14-17 years) and adult (18-80 years) patients with idiopathic slow-transit constipation refractory to conservative treatment. Intervention: The intervention is SNM, a minimally invasive surgical procedure consisting of two phases. In the screening phase an electrode is inserted near the third sacral nerve and connected to an external stimulator. If the screening phase is successful (average defecation frequency (DF) ≥3 a week), the electrode is connected to a pacemaker that is implanted in the buttocks of the patient. If not successful, the pacemaker will be removed and patients receive conservative treatment. Main study parameters/endpoints: The primary outcome is treatment success at 6 months, defined as an average DF of ≥3 a week according to a 3-week defecation diary and safety. Secondary outcomes are straining, sense of incomplete evacuation, constipation severity and generic (health-related) quality of life ((HR)QOL).

Full Title of Study: “Effectiveness and Safety of Sacral Neuromodulation in Patients With Idiopathic Slow-transit Constipation Refractory to Conservative Treatments”

Study Type

  • Study Type: Observational
  • Study Design
    • Time Perspective: Prospective
  • Study Primary Completion Date: December 2021

Interventions

  • Device: Sacral Neuromodulation
    • SNM starts with a screening phase. In this phase a tined lead is inserted into the third sacral foramen and attached to an external stimulator, after which the patient enters a four-week stimulation test period. If the screening phase is successful (defecation frequency (DF) ≥3 a week), the external stimulator is changed for a pacemaker that is implanted in the buttocks. If the screening phase is unsuccessful (DF <3 a week), the lead is explanted. Patients are asked to limit the use of additional conservative treatments for constipation (such as laxatives and colonic irrigation) to what is necessary to relieve (the most severe) complaints. What is necessary to relieve complaints is determined by the patient.

Arms, Groups and Cohorts

  • Sacral Neuromodulation (SNM)

Clinical Trial Outcome Measures

Primary Measures

  • Treatment success at 6 months
    • Time Frame: 6 months
    • Treatment success is defined as an average defecation frequency of ≥ 3 a week based on a patient-reported defecation diary over a period of 3 weeks
  • Complications/adverse events
    • Time Frame: 6 months
    • Reported by the clinician in a case report form (CRF)

Secondary Measures

  • Proportion of patients with a 50% reduction in the proportion of defecations with straining
    • Time Frame: Baseline, 1, 3 and 6 months, (12 months)
    • The proportion of defecations with straining is derived from the data in the 3 week defecation diary. The reported proportion of defecations with straining is compared with the proportion of defecations with straining at baseline. Patients are divided in two groups: 1) ≥50% reduction in the proportion of defecations with straining and 2) <50% reduction in the proportion of defecations with straining. In patients who still have the pacemaker at 6 months, outcomes are als measured 12 months after inclusion to monitor the longer term effectiveness and safety of SNM.
  • Proportion of patients with a 50% reduction in the proportion of defecations with a sense of incomplete evacuation
    • Time Frame: Baseline, 1, 3 and 6 months, (12 months)
    • The proportion of defecations with a sense of incomplete evacuation is derived from the data in the 3 week defecation diary. The reported proportion of defecations with a sense of incomplete evacuation is compared with the proportion of defecations with a sense of incomplete evacuation at baseline. Patients are divided in two groups: 1) ≥50% reduction in the proportion of defecations with a sense of incomplete evacuation and 2) <50% reduction in the proportion of defecations with a sense of incomplete evacuation. In patients who still have the pacemaker at 6 months, outcomes are als measured 12 months after inclusion to monitor the longer term effectiveness and safety of SNM.
  • Constipation severity
    • Time Frame: Baseline, 1, 3 and 6 months, (12 months)
    • Displayed with the score from the Wexner constipation score (WCS). In patients who still have the pacemaker at 6 months, outcomes are als measured 12 months after inclusion to monitor the longer term effectiveness and safety of SNM.
  • Generic (HR)QOL
    • Time Frame: Baseline, 1, 3 and 6 months, (12 months)
    • Displayed with the score from the EQ-5D-5L. In patients who still have the pacemaker at 6 months, outcomes are als measured 12 months after inclusion to monitor the longer term effectiveness and safety of SNM.

Participating in This Clinical Trial

Inclusion Criteria

  • An average defecation frequency (DF) of <3 per week based on a 3-week defecation diary (patient-reported) – Meet at least one other criterion of the Rome-IV criteria for idiopathic constipation based on the 3-week defecation diary (1) – Refractory to conservative treatment – Age: 14-80 years – Slow-transit constipation (1) Rome-IV criteria for idiopathic constipation: – Straining during ≥25% of defecations – Lumpy or hard stools in ≥25% of defecations – Sensation of incomplete evacuation for ≥25% of defecations – Sensation of anorectal obstruction/blockage for ≥25% of defecations – Manual manoeuvres to facilitate ≥25% of defecations Exclusion Criteria:
  • Obstructed outlet syndrome (objectified by defeacography) – Irritable bowel syndrome (Rome-IV criteria for irritable bowel syndrome) – Congenital or organic bowel pathology – Rectal prolapse – Anatomical limitations preventing placement of an electrode – Skin and perineal disease with risk of infection – Previous large bowel/rectal surgery – Stoma – Coexisting neurological disease – Significant psychological co-morbidity as assessed subjectively by the investigator – Being or attempting to become pregnant during study follow-up
  • Gender Eligibility: All

    Minimum Age: 14 Years

    Maximum Age: 80 Years

    Are Healthy Volunteers Accepted: No

    Investigator Details

    • Lead Sponsor
      • Maastricht University Medical Center
    • Collaborator
      • Dutch National Health Care Institute
    • Provider of Information About this Clinical Study
      • Sponsor
    • Overall Official(s)
      • Stéphanie O Breukink, Dr., Principal Investigator, Maastricht University Medical Centre
      • Carmen D Dirksen, Prof. dr., Principal Investigator, Maastricht University Medical Centre
    • Overall Contact(s)
      • Stéphanie O Breukink, Dr., +31(0)433875492, s.breukink@mumc.nl

    References

    Mugie SM, Benninga MA, Di Lorenzo C. Epidemiology of constipation in children and adults: a systematic review. Best Pract Res Clin Gastroenterol. 2011 Feb;25(1):3-18. doi: 10.1016/j.bpg.2010.12.010. Review.

    Suares NC, Ford AC. Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol. 2011 Sep;106(9):1582-91; quiz 1581, 1592. doi: 10.1038/ajg.2011.164. Epub 2011 May 24. Review.

    van Wunnik BP, Peeters B, Govaert B, Nieman FH, Benninga MA, Baeten CG. Sacral neuromodulation therapy: a promising treatment for adolescents with refractory functional constipation. Dis Colon Rectum. 2012 Mar;55(3):278-85. doi: 10.1097/DCR.0b013e3182405c61.

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